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A nurse is caring for a 6-week-old infant.

Exhibits

Specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Correct Answers:

Condition Most Likely Experiencing: C

Actions to Take: A, B

Parameters to Monitor: B, C

Rationale:

Condition Most Likely Experiencing

A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.

B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.

C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.

D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.

Actions to Take

A. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.

C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.

Parameters to Monitor
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Intake and output can indicate fluid balance and renal function.

C. Respiratory status can reflect cardiac function and oxygenation.

D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.

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Correct Answer is ["A","B","C","F","H"]

Explanation

Rationale:

A.Clients with sickle cell disease are at increased risk for infections, including those caused by pneumococcus. Ensuring vaccination status helps prevent future complications.

B. Folic acid supplementation may be part of the overall management of sickle cell disease, but it is not a priority intervention during a vaso-occlusive crisis.

C. Vaso-occlusive crises can lead to tissue hypoxia due to impaired blood flow.

Continuous monitoring of oxygen saturation helps in assessing tissue perfusion and detecting hypoxemia early.

D. Placing the client on strict bed rest can increase the risk of thrombosis and impair circulation.

E.Cold can cause vasoconstriction, worsening the pain and sickling process. Warm compresses are more appropriate for promoting comfort and improving circulation.

F. Meperidine (Demerol) is a potent opioid analgesic that can help alleviate severe pain associated with vaso-occlusive crises.

G. The nurse should not restrict oral intake, as hydration is important to prevent dehydration and further sickling.

H. Hydroxyurea is used to prevent vaso-occlusive crises in patients with sickle cell disease but is not typically administered during an acute crisis. This is a medication that reduces the frequency and severity of vaso-occlusive crises by increasing the production of fetal hemoglobin, which prevents sickling.

A. Drainage from the chest tube of 22 mL in the last hour B. Urine output of 15 mL in the last 2 hr C. Skin temperature 36° C (96.8° F) D. Pedal and posterior tibial pulses of 2+

Correct Answer is B

Explanation

Rationale:

A. This amount of drainage may be expected postoperatively, and it is not indicative of a significant issue.

B. This is a concerning finding indicating possible inadequate renal perfusion, especially considering the postoperative status of the toddler.

C. While slightly lower than the typical body temperature, it is not necessarily abnormal, particularly in a postoperative setting.

D. Pulses of 2+ indicate adequate perfusion and are not concerning.

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A nurse is caring for a 6-week-old infant. Exhibits Specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

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Explanation

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A nurse is caring for a 6-week-old infant.

Exhibits

Specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.